Provider Demographics
NPI:1003430158
Name:VANVAKAS, JORDYN
Entity Type:Individual
Prefix:
First Name:JORDYN
Middle Name:
Last Name:VANVAKAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 COVENTRY RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33897-3894
Mailing Address - Country:US
Mailing Address - Phone:863-800-2702
Mailing Address - Fax:
Practice Address - Street 1:10909 MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-2511
Practice Address - Country:US
Practice Address - Phone:813-855-4435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician